Providence executive talks about health care trends
The chief executive of Providence Medical Group says more changes in health care are on the way, specifically in how care is paid for and how services are delivered.
Dr. Doug Koekkoek says the changes are prompted by many factors: After-effects from the failed repeal of the 2010 Affordable Care Act, rising costs that outpace reimbursement for hospitals and other providers, and a changing mix of patients covered by private insurance and government programs.
All of them affect hospitals and health systems, which initially saw more people who had coverage — and fewer uninsured — after the law took effect in 2014. The result: Hospitals had less uncompensated care.
Koekkoek said one eventual result may be a single-payer system under which the government pays all medical bills — well beyond what supporters and critics of the 2010 law envisioned — or universal insurance coverage at a minimum.
"I am thinking we are five to 10 years out before that is a reality," he said at a Washington County Public Affairs Forum luncheon on May 14.
"Where we are headed right now is probably not sustainable. We will not get to a single-payer system in the current administration, maybe even in the next. Things will have to get worse before they get better. We're probably going to have to see hospitals go out of business and communities not have access to good care."
Though critics failed last year to win outright repeal of the law, Republican congressional majorities used the tax-code overhaul at the end of 2017 to remove a requirement for individuals to obtain coverage — known as the individual mandate — or pay a penalty on their tax bills.
President Donald Trump also eliminated cost-sharing reduction payments, which enabled health insurers to lower the cost of deductibles and copayments for people covered by individual policies in insurance exchanges. Without the subsidies, insurers have greatly increased premiums to offset losses.
"Because you do not have to participate (in coverage), it's a limited pool of people who have more illnesses," Koekkoek said. "So the cost of delivering care per individual in that pool goes up and insurance companies pass that along in premiums."
A settlement of a subsequent lawsuit is pending in a federal appeals court, but the litigation continues.
Trump also has pushed for barebones insurance plans — barred by the 2010 law, which sets minimum benefits — that are cheaper but come with high deductibles before coverage kicks in.
"High-deductible plans actually discourage people from getting care," Koekkoek said, because people forgo routine care that can prevent more serious conditions.
Meanwhile, he said, the share of people who are covered by employer-based insurance continues to drop, while the number covered by government-supported programs such as Medicare and Medicaid continues to grow.
According to a 2017 preliminary report by the Oregon Health Authority, 47.5 percent of Oregon's population still gets job-related coverage, 26 percent are covered by Medicaid through the Oregon Health Plan, 15 percent through Medicare, 5.2 percent from individual policies — and 6.2 percent are uninsured. (Oregon's total is virtually the same as in 2015, when 95 percent were insured.)
The biggest jump was in the Oregon Health Plan, which nearly doubled its share of population coverage since 2011. Oregon was among the 32 states that expanded Medicaid, and it did so aggressively.
But reimbursement by government programs, about 2 percent annually, is outpaced by rising costs for medical services at 4 percent.
"If costs continue to go up and reimbursements do not, we are going to have hospitals go out of business," he said. "In a city like Portland, maybe that will not be that devastating. But if you are in a one-hospital town in rural Oregon, it's going to be a big deal."
Unlike in the past, Koekkoek said, "businesses cannot pick up the double-digit premium increases (in commercial insurance) that would be necessary to offset those losses."
Providence operates St. Vincent Medical Center on Southwest Barnes Road and numerous clinics in Washington County.
Koekkoek said hospitals — most of which are now part of broader health systems with doctor networks and outpatient clinics — are changing to eliminate low-value care, reduce medical errors and improve patient safety.
Most importantly, he said, they are seeking to control costs of the small number of high-risk patients, "the sickest of the sick," who require numerous medications and specialty care.
"We need to think differently about the patients entrusted to our care," he said. "Not all of them need the same level of intervention."
He said patients with chronic conditions, such as diabetes and high blood pressure, require disease management — and many more simply require primary care.
Koekkoek said many people can remain in the low-risk category through the usual practices: A healthy diet, regular exercise, no use of tobacco and moderate use of alcohol.
"It is clear that a lot of the illness we have in our society is preventable," he said.
"We need to do more. But I doubt we can rely exclusively on health-care systems to do all those programs. Those are societal issues. I look at it as a shared obligation."
For the live Facebook presentation by Dr. Doug Koekkoek on May 14: